Botulinum toxin therapy for fibromyalgia

ABSTRACT

Methods for treating fibromyalgia by administering a therapeutically effective amount of a botulinum toxin to a patient with fibromyalgia.

CROSS REFERENCE

[0001] This application is a continuation in part of U.S. patentapplication Ser. No. 09/954,610, filed Sep. 17, 2001.

BACKGROUND

[0002] Fibromyalgia is a persistent muscle pain that can be accompaniedby severe fatigue, insomnia, diarrhea, abdominal bloating, bladderirritation and headache. The criteria for a diagnosis of fibromyalgiacan include widespread pain throughout the body accompanied bytenderness in 11 of 18 specific tender points (FIG. 1). Tenderness isdetermined by applying firm pressure over each designated area.

[0003] The underlying pathophysiology and pathology of fibromyalgia isnot well understood. Radiographic and histological examinations ofregions associated with tenderness reveal no abnormalities. Bloodchemistries, CBC, erythrocyte sedimentation rate (ESR), as well as otherimmunologic manifestations commonly known for other diseases (i.e.autoantibodies in Lupus), are normally negative unless there is anotherunderlying disorder.

[0004] The source of the pain in fibromyalgia is not clear. Nociceptorsare present in the interstitial space between muscle fibers, inparticular, on blood vessels. Studies have reported intramuscularmicrocirculation abnormalities as well as a decrease in energy-richphosphates in fibromyalgia musculature, Raj et al, Pain Digest, 8(6),357-363 (1998)). These abnormalities may be important for producingmuscle associated pain since 1) impaired microcirculation results ininsufficient delivery of oxygen to localized muscle regions whichresults in sub-optimal working capacity of the musculature which maylead to exhaustion of some motor units; and 2) reduced energy-richphosphates (ATP and phosphorylcreatine) means that demands of workingmuscles are not met by the energy supply, which may cause localizedmuscular strain, weakness, fatigue and pain.

[0005] Fibromyalgia tender points are characterized by allodynia (astate where a normally non-painful stimulus elicits a painfulperception). Muscular dysfunction, either mechanical or metabolic, canlead to a state of sensitization of the nociceptive sensory inputs intothe spinal cord altering the neurochemical balance important fornociceptive control. The process of nociception may be accomplished by acontrolled release of various pro-nociceptive and antinociceptive agentsin the nervous system. These agents include excitatory amino acids,neuropeptides, biogenic amines, nitric oxide, and prostaglandins. Oneimportant pro-nociceptive mediator is the neuropeptide substance P,which is found to be consistently elevated in the cerebrospinal fluid offibromyalgia patients. Substance P may be released by sensory afferentsarising from the muscle into the dorsal horn of the spinal cord tointeract with neurokinin-1 receptors. Activation of spinal neurons bysubstance P prepares the neurons for an inceptive pain signal, therebyfacilitating nociceptive perception. Injection of substance P intoanimals causes allodynia by increasing the number of afferent neuronsthat are activated (e.g. discharge one or more action potentials) inresponse to a certain nociceptive stimulus and reducing the voltagethreshold needed for their activation.

[0006] A recent finding of elevated nerve growth factor levels incerebral spinal fluid of patients may exacerbate the condition byincreasing the development of substance P-containing sensory neurons,which either contribute to or accentuate the painful symptoms broughtabout by an elevated level of substance P. Further, levels ofanti-nociceptive substances such as the neuropeptide met-enkephalin andbiogenic amine serotonin are found to be significantly reduced infibromyalgia patients' cerebral spinal fluid.

[0007] Fibromyalgia tends to be chronic and often occurs after astressful event suffered by the patient, either physical orpsychological. Current treatments involve massages, exercise, changes indiet and anti-depressant medication. All of these forms of treatment areinadequate only providing some benefit to a small subset of patients.

[0008] What is needed are new effective methods to treat fibromyalgia,including pain associated with fibromyalgia. The present inventionprovides methods to treat the symptoms (including pain) of fibromyalgiaby the injection of a Clostridial toxin, for example, a botulinum toxin,into a patient at a location that is not at or near a site (i.e. isanatomically distant) from which the patient perceives the pain tooriginate. It is hypothesized that botulinum toxin may interfere with acentral pain pathway through routes not traditionally associated withthe action of this neurotoxin, as may occur for example in the use of abotulinum toxin to treat a migraine headache. See e.g. U.S. Pat. No.5,714,468.

[0009] Botulinum Toxin

[0010] The anaerobic, gram positive bacterium Clostridium botulinumproduces a potent polypeptide neurotoxin, botulinum toxin, which causesa neuroparalytic illness in humans and animals referred to as botulism.The spores of Clostridium botulinum are found in soil and can grow inimproperly sterilized and sealed food containers of home basedcanneries, which are the cause of many of the cases of botulism. Theeffects of botulism typically appear 18 to 36 hours after eating thefoodstuffs infected with a Clostridium botulinum culture or spores. Thebotulinum toxin can apparently pass unattenuated through the lining ofthe gut and attack peripheral motor neurons. Symptoms of botulinum toxinintoxication can progress from difficulty walking, swallowing, andspeaking to paralysis of the respiratory muscles and death.

[0011] Botulinum toxin type A (“BoNT/A”) is the most lethal naturalbiological agent known to man. About 50 picograms of botulinum toxin(purified neurotoxin complex) serotype A is a LD₅₀ in mice. One unit (U)of botulinum toxin is defined as the LD₅₀ upon intraperitoneal injectioninto female Swiss Webster mice weighing 18-20 grams each. Sevenimmunologically distinct botulinum neurotoxins have been characterized,these being respectively botulinum neurotoxin serotypes A, B, C₁, D, E,F and G each of which is distinguished by neutralization withserotype-specific antibodies. The different serotypes of botulinum toxinvary in the animal species that they affect and in the severity andduration of the paralysis they evoke. For example, it has beendetermined that BoNt/A is 500 times more potent, as measured by the rateof paralysis produced in the rat, than is botulinum toxin serotype B(BoNT/B). Additionally, botulinum toxin type B (“BoNt/B”) has beendetermined to be non-toxic in primates at a dose of 480 U/kg which isabout 12 times the primate LD₅₀ for BoNt/A. Botulinum toxin apparentlybinds with high affinity to cholinergic motor neurons, is translocatedinto the neuron and blocks the release of acetylcholine.

[0012] Botulinum toxins have been used in clinical settings for thetreatment of neuromuscular disorders characterized by hyperactiveskeletal muscles. BoNt/A has been approved by the U.S. Food and DrugAdministration for the treatment of blepharospasm, strabismus,hemifacial spasm and cervical dystonia. Additionally a botulinum toxintype B has been approved by the FDA for the treatment of cervicaldystonia. Non-serotype A botulinum toxin serotypes apparently have alower potency and/or a shorter duration of activity as compared toBoNt/A. Clinical effects of peripheral intramuscular BoNt/A are usuallyseen within one week of injection. The typical duration of symptomaticrelief from a single intramuscular injection of BoNt/A averages aboutthree months.

[0013] Although all the botulinum toxins serotypes apparently inhibitrelease of the neurotransmitter acetylcholine at the neuromuscularjunction, they do so by affecting different neurosecretory proteinsand/or cleaving these proteins at different sites. For example,botulinum serotypes A and E both cleave the 25 kiloDalton (kD)synaptosomal associated protein (SNAP-25), but they target differentamino acid sequences within this protein. BoNT/B, D, F and G act onvesicle-associated protein (VAMP, also called synaptobrevin), with eachserotype cleaving the protein at a different site. Finally, botulinumtoxin serotype C₁ (BoNT/C₁) has been shown to cleave both syntaxin andSNAP-25. These differences in mechanism of action may affect therelative potency and/or duration of action of the various botulinumtoxin serotypes.

[0014] Regardless of serotype, the molecular mechanism of toxinintoxication appears to be similar and to involve at least three stepsor stages. In the first step of the process, the toxin binds to thepresynaptic membrane of the target neuron through a specific interactionbetween the H chain and a cell surface receptor; the receptor is thoughtto be different for each serotype of botulinum toxin and for tetanustoxin. The carboxyl end segment of the H chain, H_(c), appears to beimportant for targeting of the toxin to the cell surface.

[0015] In the second step, the toxin crosses the plasma membrane of thepoisoned cell. The toxin is first engulfed by the cell throughreceptor-mediated endocytosis, and an endosome containing the toxin isformed. The toxin then escapes the endosome into the cytoplasm of thecell. This last step is thought to be mediated by the amino end segmentof the H chain, HN, which triggers a conformational change of the toxinin response to a pH of about 5.5 or lower. Endosomes are known topossess a proton pump which decreases intra endosomal pH. Theconformational shift exposes hydrophobic residues in the toxin, whichpermits the toxin to embed itself in the endosomal membrane. The toxinthen translocates through the endosomal membrane into the cytosol.

[0016] The last step of the mechanism of botulinum toxin activityappears to involve reduction of the disulfide bond joining the H and Lchain. The entire toxic activity of botulinum and tetanus toxins iscontained in the L chain of the holotoxin; the L chain is a zinc (Zn++)endopeptidase which selectively cleaves proteins essential forrecognition and docking of neurotransmitter-containing vesicles with thecytoplasmic surface of the plasma membrane, and fusion of the vesicleswith the plasma membrane. Tetanus neurotoxin, botulinum toxin/B/D,/F,and/G cause degradation of synaptobrevin (also called vesicle-associatedmembrane protein (VAMP)), a synaptosomal membrane protein. Most of theVAMP present at the cytosolic surface of the synaptic vesicle is removedas a result of any one of these cleavage events. Each toxin specificallycleaves a different bond.

[0017] The molecular weight of the botulinum toxin protein molecule, forall seven of the known botulinum toxin serotypes, is about 150 kD.Interestingly, the botulinum toxins are released by Clostridialbacterium as complexes comprising the 150 kD botulinum toxin proteinmolecule along with associated non-toxin proteins. Thus, the BoNt/Acomplex can be produced by Clostridial bacterium as 900 kD, 500 kD and300 kD forms. BoNT/B and C₁ are apparently produced as only a 500 kDcomplex. BoNT/D is produced as both 300 kD and 500 kD complexes.Finally, BoNT/E and F are produced as only approximately 300 kDcomplexes. The complexes (i.e. molecular weight greater than about 150kD) are believed to contain a non-toxin hemaglutinin protein and anon-toxin and non-toxic nonhemaglutinin protein. These two non-toxinproteins (which along with the botulinum toxin molecule comprise therelevant neurotoxin complex) may act to provide stability againstdenaturation to the botulinum toxin molecule and protection againstdigestive acids when toxin is ingested. Additionally, it is possiblethat the larger (greater than about 150 kD molecular weight) botulinumtoxin complexes may result in a slower rate of diffusion of thebotulinum toxin away from a site of intramuscular injection of abotulinum toxin complex.

[0018] In vitro studies have indicated that botulinum toxin inhibitspotassium cation induced release of both acetylcholine andnorepinephrine from primary cell cultures of brainstem tissue.Additionally, it has been reported that botulinum toxin inhibits theevoked release of both glycine and glutamate in primary cultures ofspinal cord neurons and that in brain synaptosome preparations botulinumtoxin inhibits the release of each of the neurotransmittersacetylcholine, dopamine, norepinephrine, CGRP and glutamate.

[0019] BoNt/A can be obtained by establishing and growing cultures ofClostridium botulinum in a fermenter and then harvesting and purifyingthe fermented mixture in accordance with known procedures. All thebotulinum toxin serotypes are initially synthesized as inactive singlechain proteins which must be cleaved or nicked by proteases to becomeneuroactive. The bacterial strains that make botulinum toxin serotypes Aand G possess endogenous proteases and serotypes A and G can thereforebe recovered from bacterial cultures in predominantly their active form.In contrast, botulinum toxin serotypes C₁, D and E are synthesized bynonproteolytic strains and are therefore typically unactivated whenrecovered from culture. Serotypes B and F are produced by bothproteolytic and nonproteolytic strains and therefore can be recovered ineither the active or inactive form. However, even the proteolyticstrains that produce, for example, the BoNt/B serotype only cleave aportion of the toxin produced. The exact proportion of nicked tounnicked molecules depends on the length of incubation and thetemperature of the culture. Therefore, a certain percentage of anypreparation of, for example, the BoNt/B toxin is likely to be inactive,possibly accounting for the known significantly lower potency of BoNt/Bas compared to BoNt/A. The presence of inactive botulinum toxinmolecules in a clinical preparation will contribute to the overallprotein load of the preparation, which has been linked to increasedantigenicity, without contributing to its clinical efficacy.Additionally, it is known that BoNt/B has, upon intramuscular injection,a shorter duration of activity and is also less potent than BoNt/A atthe same dose level.

[0020] It has been reported (as exemplary examples) that BoNt/A has beenused clinically as follows:

[0021] (1) about 75-125 units of BOTOX®¹ per intramuscular injection(multiple muscles) to treat cervical dystonia;

[0022] (2) 5-10 units of BOTOX® per intramuscular injection to treatglabellar lines (brow furrows) (5 units injected intramuscularly intothe procerus muscle and 10 units injected intramuscularly into eachcorrugator supercilii muscle);

[0023] (3) about 30-80 units of BOTOX® to treat constipation byintrasphincter injection of the puborectalis muscle;

[0024] (4) about 1-5 units per muscle of intramuscularly injected BOTOX®to treat blepharospasm by injecting the lateral pre-tarsal orbicularisoculi muscle of the upper lid and the lateral pre-tarsal orbicularisoculi of the lower lid.

[0025] (5) to treat strabismus, extraocular muscles have been injectedintramuscularly with between about 1-5 units of BOTOX®, the amountinjected varying based upon both the size of the muscle to be injectedand the extent of muscle paralysis desired (i.e. amount of dioptercorrection desired). (6) to treat upper limb spasticity following strokeby intramuscular injections of BOTOX® into five different upper limbflexor muscles, as follows:

[0026] (a) flexor digitorum profundus: 7.5 U to 30 U

[0027] (b) flexor digitorum sublimus: 7.5 U to 30 U

[0028] (c) flexor carpi ulnaris: 10 U to 40 U

[0029] (d) flexor carpi radialis: 15 U to 60 U

[0030] (e) biceps brachii: 50 U to 200 U. Each of the five indicatedmuscles has been injected at the same treatment session, so that thepatient receives from 90 U to 360 U of upper limb flexor muscle BOTOX®by intramuscular injection at each treatment session.

[0031] The tetanus neurotoxin acts mainly in the central nervous system,while botulinum neurotoxin acts at the neuromuscular junction; both actby inhibiting acetylcholine release from the axon of the affected neuroninto the synapse, resulting in paralysis. The effect of intoxication onthe affected neuron is long-lasting and until recently has been thoughtto be irreversible. The tetanus neurotoxin is known to exist in oneimmunologically distinct serotype.

[0032] Acetylcholine Typically only a single type of small moleculeneurotransmitter is released by each type of neuron in the mammaliannervous system. The neurotransmitter acetylcholine is secreted byneurons in many areas of the brain, but specifically by the largepyramidal cells of the motor cortex, by several different neurons in thebasal ganglia, by the motor neurons that innervate the skeletal muscles,by the preganglionic neurons of the autonomic nervous system (bothsympathetic and parasympathetic), by the postganglionic neurons of theparasympathetic nervous system, and by some of the postganglionicneurons of the sympathetic nervous system. Essentially, only thepostganglionic sympathetic nerve fibers to the sweat glands, thepiloerector muscles and a few blood vessels are cholinergic and most ofthe postganglionic neurons of the sympathetic nervous system secret theneurotransmitter norepinephine. In most instances acetylcholine has anexcitatory effect. However, acetylcholine is known to have inhibitoryeffects at some of the peripheral parasympathetic nerve endings, such asinhibition of the heart by the vagal nerve.

[0033] The efferent signals of the autonomic nervous system aretransmitted to the body through either the sympathetic nervous system orthe parasympathetic nervous system. The preganglionic neurons of thesympathetic nervous system extend from preganglionic sympathetic neuroncell bodies located in the intermediolateral horn of the spinal cord.The preganglionic sympathetic nerve fibers, extending from the cellbody, synapse with postganglionic neurons located in either aparavertebral sympathetic ganglion or in a prevertebral ganglion. Since,the preganglionic neurons of both the sympathetic and parasympatheticnervous system are cholinergic, application of acetylcholine to theganglia will excite both sympathetic and parasympathetic postganglionicneurons.

[0034] Acetylcholine activates two types of receptors, muscarinic andnicotinic receptors. The muscarinic receptors are found in all effectorcells stimulated by the postganglionic neurons of the parasympatheticnervous system, as well as in those stimulated by the postganglioniccholinergic neurons of the sympathetic nervous system. The nicotinicreceptors are found in the synapses between the preganglionic andpostganglionic neurons of both the sympathetic and parasympathetic. Thenicotinic receptors are also present in many membranes of skeletalmuscle fibers at the neuromuscular junction.

[0035] Acetylcholine is released from cholinergic neurons when small,clear, intracellular vesicles fuse with the presynaptic neuronal cellmembrane. A wide variety of non-neuronal secretory cells, such as,adrenal medulla (as well as the PC12 cell line) and pancreatic isletcells release catecholamines and insulin, respectively, from largedense-core vesicles. The PC12 cell line is a clone of ratpheochromocytoma cells extensively used as a tissue culture model forstudies of sympathoadrenal development. Botulinum toxin inhibits therelease of both types of compounds from both types of cells in vitro,permeabilized (as by electroporation) or by direct injection of thetoxin into the denervated cell. Botulinum toxin is also known to blockrelease of the neurotransmitter glutamate from cortical synaptosomescell cultures.

SUMMARY

[0036] In accordance with the present invention, there are providedmethods for treating fibromyalgia. These methods may includeadministering locally a therapeutically effective amount of aClostridial toxin to a peripheral location on a body of a patientafflicted with fibromyalgia. The peripheral location of localadministration is not a locus of pain. For example, the peripherallocation may be on the body of a patient about one centimeter or morefrom the locus of pain. In one embodiment, the locus of pain is afibromyalgia tender point.

[0037] In one embodiment of the present invention, a dermatome mayinclude both the locus of pain, for example, where a pain associatedwith fibromyalgia is perceived by the patient to originate, and theperipheral location where the therapeutically effective amount of aClostridial toxin is administered.

[0038] In another embodiment, the peripheral location where an effectiveamount of Clostridial neurotoxin is administered is in the head of thepatient. For example, the neurotoxin may be administered to the facialarea and/or cranial area of the head. In this embodiment, where aneffective amount of Clostridial neurotoxin is administered in the headof the patient, the locus of pain to be treated is not in the head. Forexample, the locus of pain may be at a fibromyalgia tender point.

[0039] Further in accordance with the present invention, there areprovided methods for treating pain which may include administeringlocally a therapeutically effective amount of a Clostridial toxin to aperipheral location on a body of a patient. The site of localadministration is other than a locus of pain. A dermatome may includeboth a locus of pain and a site of local administration. In oneembodiment, the locus of pain may be at a fibromyalgia tender point. Inone embodiment, a patient has at least eleven loci of pain.

[0040] Further in accordance with the present invention, there areprovided methods for treating fibromyalgia. These methods may includeadministering locally a therapeutically effective amount of aClostridial toxin to a dermatome of a patient afflicted withfibromyalgia. This dermatome may substantially include a locus of pain.The local administering is not at a locus of pain. In one embodiment ofthe invention, the locus of pain is at one or more fibromyalgia tenderpoints.

[0041] Methods for treating pain are within the scope of the invention.These methods may administering locally a therapeutically effectiveamount of a Clostridial toxin at a location in a dermatome other than alocus of pain. This dermatome also includes a locus of pain. The locusof pain may be at a fibromyalgia tender point.

[0042] Further in accordance with the present invention, there areprovided methods for treating fibromyalgia pain. These methods include astep of administering a therapeutically effective amount of botulinumtoxin type A to a dermatome. This dermatome may include a site where thepain is perceived by the patient to originate.

[0043] Still further in accordance with the present invention, there areprovided methods for treating pain which is perceived to originate atfibromyalgia tender point. These methods include a step of administeringa therapeutically effective amount of botulinum toxin type A to alocation in a dermatome other than where the pain is perceived tooriginate. This dermatome includes the site where the pain is perceivedto originate. A toxin used in accordance with the present invention maybe botulinum toxin type A, B, C₁, C₂, D, E, F, G or fragments of thesetoxins or derivatives of these toxins. In one embodiment of the presentinvention, the toxin may be a mixture or combination of these botulinumtoxins.

[0044] The location where the therapeutically effective amount of atoxin is administered and the site where a pain is perceived by thepatient to originate may have neuronal processes that project from thesame spinal sensory nerve root.

[0045] Further in accordance with the present invention, a toxin may beadministered, for example, subcutaneously or intramuscularly. Further,the toxin may be administered with a needle or by needleless injection.

[0046] In one embodiment of the present invention, there is provided amethod for treating fibromyalgia which may include administering locallya therapeutically effective amount of a botulinum toxin type A to adermatome of a patient afflicted with fibromyalgia. The dermatomesubstantially encompasses a locus of pain and the locus of pain is at afibromyalgia tender point. The local administration is not at the locusof pain.

[0047] In one embodiment of the present invention, there is provided amethod for treating pain which may include administering locally atherapeutically effective amount of a botulinum toxin type A to adermatome of a patient. The patient has a locus of pain which is at afibromyalgia tender point, wherein the dermatome substantiallyencompasses the locus of pain, and wherein the local administration isnot to the locus of pain.

[0048] My invention also includes a method for treating fibromyalgia byadministering a botulinum toxin to a patient with fibromyalgia. Asstated, the botulinum toxin can be a botulinum toxin type A, B, C, D, E,F or G. The botulinum toxin can be administered subcutaneously orintramuscularly.

[0049] Another embodiment of my invention is a method for treating afibromyalgia pain by administering a botulinum toxin to a patient withfibromyalgia. The botulinum toxin administering being carried out at afirst location. This first location is anatomically distinct from and/oranatomically distant from a second location. Similarly, any part of anarm is not anatomically contiguous with any part of a leg, and viceversa. “Anatomically distinct” means that the functional anatomy of thefirst and second locations is not contiguous, in a functional anatomicalsense. For example, all parts of a leg, or all parts of an arm areanatomically contiguous. But any part of the head or any part of theneck is not anatomically contiguous to any part of a leg, arm or back.“Anatomically distant” is a synonym for anatomically distinct. At thesecond location the patient has a fibromyalgia pain which is alleviatedby the administration of the botulinum toxin at the first location. Thefirst location can be a peripheral location and the second location canbe a locus of pain. Preferably, the first location is the head or neckof the patient.

[0050] These and other aspects and advantages of the present inventionare apparent in the following detailed description and claims.

[0051] Definitions

[0052] “Administering locally” means administering a pharmaceutical by anonsystemic route, such as by intramuscular or subcutaneous injection orimplantation of a suitable implant. Thus, for example, oral andintravenous routes of administering are excluded from the scope of“administering locally.”

[0053] “Clostridial toxin” means a toxin produced naturally by the genusof bacteria Clostridium. For example, Clostidial toxins include, but arenot limited to, botulinum toxins, tetanus toxins, difficile toxins andbutyricum toxins. A Clostridial toxin can also be made by knownrecombinant means by a non-Clostridial bacterium.

[0054] “Combination” means an ordered sequence of elements. For example,a combination of botulinum toxins may mean administration of botulinumtoxin E, followed by administration of botulinum toxin type A, followedby administration of botulinum toxin type B. This is opposed to a“mixture” where, for example, different toxin types are combined priorto administration.

[0055] “Dermatome” means a segment of a human body innervated by asingle dorsal root. Dermatomes follow a highly regular pattern on thebody (FIG. 3) and are categorized into four major regions, the cervical(C), the thoracic (T), the lumber (L) and the sacral (S) regions (FIG.3). A dermatome may substantially encompass a locus of pain.

[0056] “Derivative” means a chemical entity which is slightly differentfrom a parent chemical entity but which still has a biological effectsimilar, or substantially similar, to the biological effect of thechemical entity. The biological effect of the derivative may besubstantially the same or better than that of the parent. For example, aderivative neurotoxin component may have one or more amino acidsubstitutions, amino acid modifications, amino acid deletions and/oramino acid additions. An amino acid substitution may be conservative ornon-conservative, as is well understood in the art. In addition,derivatives of neurotoxin components may include neurotoxin componentsthat have modified amino acid side chains, as is well known in the art.

[0057] An example of a derivative neurotoxin component may comprise alight chain of a botulinum toxin having one or more amino acidssubstituted, modified, deleted and/or added. For example, a derivativelight chain may have the same or an increased ability to preventexocytosis compared to the native light chain. For example, preventingthe release of neurotransmitter vesicles. Additionally, the biologicaleffect of a derivative may be decreased compared to the parent chemicalentity. For example, a derivative light chain of a botulinum toxin typeA having an amino acid sequence removed may have a shorter biologicalpersistence than that of the parent (or native) botulinum toxin type Alight chain.

[0058] “Fibromyalgia tender point” or “tender point” means an area of ahuman body which when firm even, pressure is applied pain may result.Elicitation of pain from 11 of 18 fibromyalgia tender points, byapplication of firm even pressure, results in a diagnosis offibromyalgia. FIG. 1 shows the location of the tender points. They are:a) occiput, suboccipital muscle insertions; b) trapezium, midpoint ofthe upper border; c) supraspinatus, above the medial border of thescapular spine; d) gluteal, upper and outer quadrant of buttocks; e)greater trochanter, posterior to the trochanteric prominence; f) lowcervical, anterior aspects of the intertransverse spaces; g) second rib,second costochondral junctions; h) lateral epicondyle, 2 centimetersdistant to the epicondyles; and i) knee, medial fat pad proximal to thejoint line.

[0059] “Fragment” means a portion of an amino acid sequence thatcomprises five amino acids or more of the native amino acid sequence upto a size of minus at least one amino acid from the native sequence. Forexample, a fragment of a botulinum toxin type A light chain comprisesfive or more amino acids of the amino acid sequence of the nativebotulinum toxin type A light chain up to a size of minus one amino acidfrom the native light chain.

[0060] “Locus of pain” means a site or location on a body of a patientwhere the patient perceives that a pain is emanating from and/or a siteor location on a body of a patient where application of pressure resultsin pain. For example, a locus of pain may be at a fibromyalgia tenderpoint. Furthermore, a locus pain may have certain discrete physicalboundaries. For example, a locus of pain may include a dermis area ofless than about 4 cm², 12 cm², 40 cm² or 60 cm². The locus of pain mayextend to tissues directly below the dermis area. For example, the locusof pain may extend about 0.5 cm, 1.0 cm, 2 cm, 4 cm or 6 cm below thedermis area.

[0061] “Needleless injection” means injecting a measurable amount ofsubstance, for example, a carrier coated with a botulinum toxin withoutthe use of a standard needle.

[0062] “Neurotoxin” means a chemical entity (i.e. a molecule) that iscapable of interfering with or influencing a function of a neuron orother target cell. For example, a neurotoxin may interfere with thetransmission of an electrical signal from a nerve cell to its target.The target may be, for example, another nerve cell, a tissue or anorgan. The “neurotoxin” may be naturally occurring or synthetic.

[0063] “Peripheral location” means a site on or in the periphery of amammals' body, such as in or under the skin or a skeletal muscle.Peripheral location excludes a site within the viscera or in the centralnervous system.

[0064] “Substantially” means largely but not entirely. For example,substantially encompassing may mean encompassing 10%, 20%, 30%, 40% or50% or more.

DRAWINGS

[0065]FIG. 1 shows the location of fibromyalgia tender points.

[0066]FIG. 2 shows the segmental accumulation of radiolabeled botulinumtoxin in the spinal cord of a rat. (From Habermann,Naunyn-Schmiedeberg's Arch Pharmacol 281, 47-56 (1974)).

[0067]FIG. 3 shows the location of human dermatomes.

[0068]FIG. 4 shows three spinal cord segments with their correspondingdorsal roots innervating three common areas of a skin.

DESCRIPTION

[0069] The present invention is based upon the discovery that abotulinum toxin can be used to effectively treat fibromyalgia. In oneembodiment, the invention relates to methods for treating painassociated with fibromyalgia and pain associated with fibromyalgiatender points.

[0070] It has been reported that botulinum toxin is ineffective to treatfibromyalgia, see Paulson et al, Mov Dis 11(4), 459 (1996) and Childerset al, Musculoskeletal Rehabilitation 10, 89-96 (1998). In thesereports, botulinum toxin was injected into the site of fibromyalgiaassociated pain (shoulder muscles). George Paulson, co-author of oneabove cited article, has stated; “Based on our experience, we suggestthat patients with fibromyalgia are unlikely to benefit from botulinumtoxin injection” (Paulson et al).

[0071] Methods for treating a symptom of fibromyalgia (including pain)by non-systemic administration of a therapeutic amount of neurotoxin arewithin the scope of the present invention. In one broad embodiment ofthis invention, a neurotoxin is administered to a site on the body of apatient other than a site where the pain to be treated is perceived tooriginate. For example, a neurotoxin may be administered to a site otherthan a tender point to be treated in association with fibromyalgia.

[0072] The locations of fibromyalgia tender points are shown in FIG. 1.Pain may be perceived to originate from these locations in afibromyalgia patient. The pain may be centered at these, or other sitesand may be accompanied by an emanating diffuse pain. In one embodiment,pain may be perceived to originate at a location on a body if thelocation is pain sensitive when firm, even pressure is applied.

[0073] Preferably, the neurotoxin used to practice a method within thescope of the present invention is a Clostridial toxin, or fragmentsthereof, or derivatives thereof. For example, botulinum toxin serotypesA, B, C, D, E, F or G may be used. Because of reasons including its highpotency in humans and ready availability, the botulinum toxin preferablyused is botulinum toxin type A.

[0074] Without wishing to be limited to any theory or mechanism ofoperation, it is hypothesized that pain pathways and/or pain feedbackloops are influenced by neurotoxins, for example, botulinum toxins,administered in accordance with the present invention. For example,neurotoxins may act through the afferent nerve pathways to block therelease of pain transmitters, for example, substance P. This mechanismof operation may be related to that by which peripheral administrationof botulinum toxin is known to alleviate pain associated with migraineheadache, see Binder, U.S. Pat. No. 5,714,468; Yue, U.S. Pat. No.5,863,552; First, U.S. Pat. No. 6,063,768; Yue, U.S. Pat. No. 5,707,642;Sanders, U.S. Pat. No. 5,766,606; and Aoki, U.S. Pat. No. 6,113,915. Thedisclosure of these patents is herein incorporated in its entirety byreference.

[0075] In support of this theory, treatment of pain by intraspinaladministration of botulinum toxin has been proposed. See Aoki et al,U.S. Pat. No. 6,136,551 and Foster et al, U.S. Pat. No. 5,989,545. Thedisclosure of these patents is herein incorporated in its entirety byreference. Further, neurotoxins, for example, botulinum toxin type A,have been shown to be retrogradely transported to the spinal cordfollowing injection of the toxin into either the hind limb or forelimbof a rat (Habermann, Naunyn-Schmiedeberg's Arch Pharmacol. 281, 47-56(1974), incorporated herein in its entirety by reference). In thisstudy, dialyzed, radiolabeled botulinum toxin (about 0.2 ug/ml) wasinjected into either the left gastronemius or the left foreleg of ratsin a volume of 0.2 ml/100 g body weight. All animals were killed andtheir spinal cords removed and radiolabeled botulinum toxin wasquantitated. The results suggest that botulinum toxin ascends to thespinal area by retrograde transport (FIG. 2). Further, Wiegand et al,Naunyn-Schmiedeberg's Arch Pharmacol 292, 161165 (1976), incorporatedherein in its entirety by reference, have also shown that radiolabeledbotulinum toxin travels to the spinal cord after intramuscularinjection. Wiegand et al state that: “obviously the [radiolabeledbotulinum toxin] reaches the spinal cord by neural ascent via theventral roots.” Several findings by Wiegand et al support thishypothesis. For example, after injection of the labeled toxin, agradient of radiolabel was found to form in the sciatic nerve. Inaddition, a significant level of radioactivity was found in the ventralroots giving rise to the innervation of the injected muscle. Also, thisradioactivity was localized exclusively within the axons of the neurons.Further, a ligature of the left ventral root prevented the radiolabeledbotulinum from reaching the corresponding segment of the spinal cordhalf segment.

[0076] The idea that botulinum toxins move through the afferent nervepathways by retrograde transport is further supported by the distanteffect botulinum toxin may have when administered by intramuscular orsubcutaneous injection. For example, there is electrophysiologicalevidence that botulinum toxin type A can effect muscle spindle output,by the Ia afferent signal, Filippi et al, Acta Otolaryngologica 113,400-404 (1993). Remote effects of botulinum toxins at distant body partshave been reported by Nix et al (Neurology 42, 602-606 (1992)). Inaddition, it has been proposed that the mode of action of botulinum typeA on focal dystonias is through the afferent pathways in addition to thewell-known effect at the alpha motor neuron nerve terminals, Giladi, Jof Neuro Sci 152, 132-135 (1997). Each of these publications isincorporated herein in its entirety by reference. It is possible thatpart of the mechanism of action of botulinum toxin in treating focaldystonias is that retrograde transport of the toxin to the spinal areatakes place and inhibition of the release of pain producing substancesresults, for example, inhibition of substance P release. In support ofthis, botulinum toxins have been shown to markedly inhibit the releaseof substance P in neuron cell cultures, Welch et al, Toxicon 38, 245-258(2000). The ability of a neurotoxin, for example, a botulinum toxin, toinhibit the release of a pain producing substance at a location in thebody distant to the site of administration of the toxin is important forat least one theory of operation of the present invention.

[0077] Without wishing to limit the invention to any theory or mechanismof operation, it is hypothesized that the afferent nerve pathwaysinnervating the tissue at the point of origin of certain types of pain,for example pain associated with fibromyalgia, may be effected in amanner so as to disallow the effect of a neurotoxin, for example, abotulinum toxin, on the release of pain producing substances. Forexample, the ability of a botulinum toxin to move by retrogradetransport in afferent pathways may be blocked. The present inventionallows for bypassing a blockage by administration of the neurotoxin to alocation that is not at or near the site of pain origin. For example,the neurotoxin may be administered to a location on a body other than asite on the body where a pain is centered. The toxin may then move byretrograde transport up the afferent neural pathway and into the spinewhere a local or regional inhibition of release of pro-nociceptivemediators, for example substance P, may take place. Release ofnociceptive mediators into the dorsal root that leads to innervation ofthe site of pain may be inhibited resulting in a subsidence of pain, forexample, subsidence of pain at the origin of the pain. Further, it maybe preferable to administer the neurotoxin to a region of a body that isinnervated by the same dorsal root that innervates the site of pain tobe treated. Doing so may allow for the most direct route for the toxinto reach the sensory neurotransmitters associated with the site of pain.

[0078] The data of Habermann and Wiegand et al show a segmentaldistribution of botulinum toxin accumulation in the spinal cord of ratsafter intramuscular injection. The distribution was determined by theinnervation of the muscles which were injected with the toxin. Thegraphs of FIG. 2 show the accumulation of radioactivity in the spinalcord following injection of the toxin. Graph A shows the results forinjection into the hind limb and graph B shows the results for injectioninto the forelimb. The X-axis of each graph represents the segment ofthe rat's spinal cord examined for radioactive deposit. It can be seenthat an injection of the labeled toxin into the hind limb causesradioactivity to appear in lumbar segment 2 of the cord, whereas aninjection into the forelimb results in deposit of radioactivity incervical segments 6 and 7 of the cord.

[0079] Segments of a human body innervated by a single dorsal root areknown as dermatomes (FIG. 3). Since one dorsal root may innervate asingle dermatome, a neurotoxin, for example, a botulinum toxin, may beadministered to a location at or near a dermatome encompassing a site ofpain to be treated. In one embodiment of the invention, the neurotoxinis administered to a dermatome that encompasses the site, or point oforigin, of pain to be treated, for example, a fibromyalgia tender point.In this embodiment, the neurotoxin is administered to a location on thebody of the patient that is not at or near the site of pain origin.

[0080] Dermatomal boundaries may overlap as is shown in FIG. 4.Therefore administration of toxin into a dermatome that does notencompass the site of pain origin to be treated may be effective.Therefore, in one embodiment of the invention, the neurotoxin isadministered to a dermatome that is adjacent to the dermatome whichcontains the site of pain origin. In another embodiment of theinvention, the neurotoxin is administered to a dermatome that is one ormore dermatomes away from the dermatome which contains the site of painorigin.

[0081] In one broad embodiment, the neurotoxin may be administered to asite on the body of a patient that is about 0.1 centimeters or more fromthe site of pain origin. In another embodiment, the neurotoxin may beadministered to a location on the body of a patient that is about 1centimeter or more from the site of pain origin. In another embodiment,the neurotoxin is administered to a location on the body of a patientthat is about 4 centimeters or more from the site of pain origin. Instill another embodiment of the invention, the neurotoxin isadministered to a location on the body of a patient that is about 8centimeters or more from the site of pain origin. In still anotherembodiment of the invention, the neurotoxin is administered to alocation that is about 0.1 centimeter to less than about 200 centimetersfrom the site of pain origin. In still another embodiment of theinvention, the neurotoxin is administered to a location that is about 1centimeter to less than about 6 centimeters from the site of painorigin. In still another embodiment of the invention, the neurotoxin isadministered to a location that is about 3 centimeter to about less thanabout 100 centimeters from the site of pain origin.

[0082] Generally, the dose of neurotoxin to be administered will varywith the age, presenting condition and weight of the patient to betreated. The potency of the neurotoxin will also be considered. Toxinpotency is expressed as a multiple of the LD₅₀ value for a mouse. One“unit” of toxin can be defined as the amount of toxin that kills 50% ofa group of mice that were disease-free prior to inoculation with thetoxin. For example, commercially available Botulinum toxin A typicallyhas a potency such that one nanogram contains about 40 mouse units. Thepotency, or LD₅₀ in humans of the Botulinum toxin A product supplied byAllergan, Inc. under the registered trademark “BOTOX” is believed to beabout 2,730 mouse units.

[0083] The neurotoxin can be administered in a dose of about 0.1 unitsup to about 1,000 units. In one embodiment, individual dosages of about15 units to about 30 units are used. In another embodiment, individualdosages of about 30 units to about 60 units are used. In still anotherembodiment, individual dosages of about 60 units to about 180 units areused. Generally, the neurotoxin will be administered as a composition ata dosage that is proportionally equivalent to about 2.5 cc/100 units.Those of ordinary skill in the art will know, or can readily ascertain,how to adjust these dosages for neurotoxin of greater or lesser potency.

[0084] Preferably, the lowest therapeutically effective dosage will beinjected into the patient. The lowest therapeutic dosage is that dosagewhich results in detection by the patient of a reduction in theoccurrence and/or magnitude of pain experienced by the patient, forexample, pain experience by a patient which is associated withfibromyalgia.

[0085] Methods for assessing or quantifying the amount of painexperienced by a patient are well known to those skilled in the art. Forexample, a patient can be given a pain assessment test in which thepatient quantifies the degree of pain based on a scale. One examplewould be assigning the patient's pain a number based on a scale of 1 to10, where a “10” would indicate the worst degree of pain the patientmight imagine. A pain measure of 4 from an original pain score of 8would be a 50% reduction in pain. Thus, the amount of conjugate requiredto achieve that 50% reduction in pain could be considered 1 U of thebotulinum toxin component-targeting moiety conjugate. Alternatively, thepatient's pain may be measured as the duration of pain. One unit of theconjugate of the invention would accordingly reduce the duration of painby 50%. In addition, a number of physiological measures, such as heartrate, respiratory rate, blood pressure, and diaphoresis, may be usedalone or together with the patientive methods described above, toquantify the amount of the patient's pain.

[0086] In an initial treatment, a low dosage may be administered at onesite to determine the patient's sensitivity to, and tolerance of, theneurotoxin. Additional injections of the same or different dosages willbe administered as necessary. For example, if pain predominates in theshoulder region (FIG. 1), the patient may receive about 40 units in thecervical region, for example, in dermatome C7. In one embodiment, thepatient receives 40 units in the C7 dermatome of the cervical region andmay also receive 40 units of the neurotoxin in the C8 and/or C6dermatomes.

[0087] In one embodiment, the site of injection is intramuscular.However, for some indications, extramuscular injection may be the mostefficacious route of administration as well as a route which avoids therisk of trauma to muscle tissue. Such injection may, for example, bemade subcutaneously or, preferably, perivascularly (to produceinfiltration of the neurotoxin into innervated tissue). In oneembodiment, the site for injection of the neurotoxin is in or near theextramuscular regions.

[0088] The neurotoxins may be administered by, for example, injectionusing a needle or by needleless injection.

[0089] In needleless injection delivery methods, microprojectile drugparticles may be coated with a neurotoxin and then discharged into theskin from an external delivery device. Depending on the dischargevelocity and the distance from the injection site, the drug particlespenetrate through the stratum corneum to different layers of theepidermis, dermis and underlying muscle. As the microprojectilespenetrate through epidermal and dermal cells, or are deposited in thesecells, the neurotoxin is released. Individual layers of skin cells orunderlying muscle cells may be targeted for the microprojectiles.

[0090] For intramuscular injections using a needle, to ensure that theneurotoxin is delivered to the target site without substantial systemicdistribution, electromyographical (“EMG”) injection may be used. Apreferred technique for EMG injection is to introduce the neurotoxinthrough a monopolar hollow bore needle (commonly, one which is coatedwith a non-stick surface such as “TEFLON®”, a trademarked product ofDuPont Nemours, of Massachusetts). The needle is placed through the skinand into the target site of a muscle, preferably at a neuromuscularjunction. Once the needle has been inserted, the most active site of themuscle can be determined by observation of the EMG signal. Those ofordinary skill in the art will know of, or can readily ascertain, othersuitable techniques for administering EMG injections.

[0091] The injections will be repeated as necessary. As a generalguideline, Botulinum toxin A administered into or near muscle tissueaccording to the method of the invention has been observed to produceflaccid paralysis at target site muscles for up to about 3 to about 6months. Reduction of pain, for example, pain associated withfibromyalgia, in patients who received the neurotoxins of the inventionextramuscularly may persist for extended periods of time. However,botulinum toxin type A in particular is expected to be most effectivewhen administered according to the method of the invention at about 3month intervals. The invention having been fully described, examplesillustrating its practice are set forth below. These examples shouldnot, however, be considered to limit the scope of the invention, whichis defined by the appended claims.

EXAMPLES Example 1

[0092] A 37-year old woman complains of pain “all over,” specifically inthe occiput, neck, shoulders, lower back, hips, and right leg.

[0093] At the time of evaluation, the patient complains specifically ofoccipital headache, which she describes as burning and aching. Shecomplains of neck pain and stiffness. Aching pain in the upper back andshoulders is constant, as is pain in a band-like fashion across thelower back. She also notes a great increase in her upper back and neckpain. The patient injures her lower back one year prior to thisevaluation-while working as a nurse's aide as she transfers a patient.She subsequently continues to experience lower back, hip, and right legpain and stiffness.

[0094] The patient reports a high level of anxiety and stress in herlife which she feels is due to her separation and pending divorce fromher husband, as well as a worsening of her pain. Her sleep isinterrupted by pain several times nightly and a general lack of energyis reported.

[0095] Upon examination, it is found that the patient tests positive forpain sensitivity in 11 of the 18 fibromyalgia tender points (FIG. 1).Specifically, tenderness is present in the left and right occiput, theleft and right cervical regions, the left and right trapezious, the leftand right gluteal, the left and right supraspinatus and the rightgreater trochanter. A diagnosis of fibromyalgia is made.

[0096] The patient is treated by intramuscular injection of 40 units ofbotulinum toxin type A into each of dermatomes C3, C5, C8, L3 and L5.Each of these dermatomes includes, or is adjacent to, a positive testingtender point. Each injection is no closer than one centimeter to atender point. Within one week of treatment, the patient notes asubstantial decrease in pain felt throughout her body. Most notable isthe decrease in pain associated with the tenderpoints. The patient nownotes little discomfort when pressure is applied to these points. Painrelief lasts for approximately four months.

Example 2

[0097] A physical examination reveals a slender 38-year old woman in nodistress. The patient walks with a normal gait and is able to performheel walk and toe walk without difficulty. Range of motion of the lumbarand cervical spine is complete but painful in extremes of range. Motorand sensory examination of the upper and lower extremities reveals mildS1 sensory loss on the right side. Reflexes are intact at the knees andankles. Straight leg raise is negative. Further examination reveals thepresence of multiple tender points in the occipital, lower cervical,trapezium, gluteal, and greater trochanter areas bilaterally.

[0098] Radiographics of the cervical and lumbar spine are essentiallynormal demonstrating only mild degenerative changes. Past medicalhistory includes asthma and hypertension. Past surgical history includesrepair of a uterine rupture.

[0099] A physician applies firm, even pressure sequentially to the 18fibromyalgia tender points and notes a positive pain sensitivity in 12of the points. The patient is diagnosed with fibromyalgia. She istreated with subcutaneous injections of 60 units of botulinum toxin typeA approximately 5 centimeters from the occipital, lower cervical,trapezius, gluteal, and greater trochanter tender points (FIG. 1). Afterapproximately 6 days the patient reports herself to be pain free. Thepatient also reports little impairment to her mobility as a result ofthe botulinum toxin injection. The relief from pain lasts approximately6 months at which time the injections are repeated.

Example 3

[0100] A 37 year old woman visits a sleep clinic. She reports a 5 monthshistory of nocturia, active and exhaustive dreaming, and daytimesleepiness. Two months prior to this visit the woman visits anotherclinic for an evaluation of unrestful sleep. At this clinic, she isprescribed sleep medication (Benadryl) which has little effect. Thepatient complains of general fatigue and “muscular achiness”, which sheattributes to her lack of sleep. The pain felt by the patient appears toradiate from specific points on the patient's body. These points includefibromyalgia tender points of the left and right knees, left and rightgluteal, left and right trapezius and the left and right occiput, leftand right low cervical, and left and right second ribs. The patientshows sensitivity when firm pressure is applied to these points. Thepatient reports high stress and anxiety as a result of going through a“painful” divorce eight months prior to the onset of symptoms. Adiagnosis of fibromyalgia is made, for which the patient is prescribedamytriptyline (Elavil®). Despite improvement in sleep, the muscle painpersists. In the previous month, the pain the patient experiencesnegatively impacts her work performance.

[0101] The patient is treated by intramuscular injection of 30 units ofbotulinum toxin into each of dermatomes L4, S1, C7 and C3. Allinjections are about four centimeters from a site of a diagnosedfibromyalgia tender point. One week after treatment the patient reportsapproximately a 50% reduction in pain which lasts for approximately 4months.

Example 4

[0102] A 28 year old woman is referred to a rheumatology clinic from herHMO primary care physician after she complains of diffuse muscle painthat is centered in her trapezium, subscapularis, gluteal, and greatertrochanteric regions. The pain persists for over 4 years with anincrease in pain in the past six months. The patient also reportsunrestful sleep characterized by excessive dreams, sensitivity to noiseand light, and nocturia. Through her professional school education (thepatient is a licensed medical technologist), a self diagnosis offibromyalgia is made, and through a family friend, she obtains aprescription for Elavil®. Initially, the Elavil® helps the patient sleepwhich may reduce some muscle soreness. Recently, however, much of thedrug's effectiveness has been lost. Up to two months prior to thisoffice visit, the patient is on 100 mg Elavil® at bedtime, which issupplemented with 25 mg Prozac® in the morning. When the patientdiscovers that she is pregnant, she ceases taking all medications. Sincethen, the pain worsened. Due to the relative safety of localizedintramuscular injection of botulinum toxin during pregnancy, botulinumtoxin injection treatment is recommended. Three subcutaneous injections,of 10 units of botulinum toxin type A are made into each of thedermatome regions C7, C8, L5 and S1. All injections are made about 6centimeters from the area where pain is centered. Over a two weekperiod, pain is completely alleviated. The patient reports animprovement in sleep pattern and an overall sense of well being.Cessation of pain lasts for 3 months at which time the injections arerepeated.

Example 5

[0103] A 30 year old coal miner visits his family physician with chiefcomplaints of persistent pain in the upper and lower back, “numbness” ofthe hands and feet, and sensation of swollen hands. Upon questioning,the man discloses bouts of gastrointestinal discomfort, both before andafter meals. The patient denies any drug use or cigarette smoking,except for an occasional alcoholic drink. He also denies any disturbancein sleep, except sometimes the headaches keep him up “all night long.”Visual observation reveals a man not under distress, and examination ofthe hands found no evidence of swollenness. Cranial tests are normal.Reflexes are normal. Palpation at 5 different areas along the axialspine, including the shoulder, occipital, and gluteal regions revealslight tenderness with moderate pressure. No tenderness is found in anyother locations. A blood chemistry is ordered. With an exception of aslightly lower K+ level, all other values are normal. Antinuclearantibody, rheumatoid factor, creatine kinase, magnesium, lyme titre, andthyroid function tests are negative. A diagnosis of fibromyalgia isinappropriate since only 5 of the 11 fibromyalgia tender points arepressure sensitive. The physician prescribes intramuscular injections of10 units of botulinum toxin type A into the sternocleidomastoid andgluteus maximus. Each injection is made about 3 centimeters from a siteof tenderness. After one week, the patient reports only mild relief.Further injections are made in the sclaneus anterior, serratus anterior,lattismus dorsi, quadriceps femoris, and semitendinosus. Pain relief,including persistent headaches and irritable bowel, is realized one weekafter this treatment.

Example 6

[0104] A 34-year-old woman seeks medical attention for generalized painthroughout her body which she perceives as originating from numerouslocations. The patient reports the symptoms persisting for the past 5months. In addition, the patient reports feelings of fatigue and aninability to obtain restful sleep. She also states that she has beenunder extreme stress during the past two years resulting from workingfull time and raising four children. In addition, approximately one yearbefore the onset of symptoms, the patient is in an automobile collisionwhere she receives internal injuries to her spleen which is subsequentlyremoved. Physical examination reveals the presence of 14 fibromyalgiatender points on her body showing pain sensitivity when firm pressure isapplied to them. These sites include the left and right low cervical,left and right second rib, left and right gluteal, left and righttrapezius, left and right knee, right greater trochanter, left lateralepicondyle and left and right occiput regions. A diagnosis offibromyalgia is made. The patient objects to the prescribing ofantidepressants for the condition and refuses the medication.

[0105] The fibromyalgia associated pain is treated with injection of 20units of botulinum toxin type A, B, C₁, C₂, D, E, F or G into dermatomesencompassing, or into dermatomes adjacent to dermatomes encompassing,the sites of tenderness. These dermatomes are C3 T2, L5, C6, L3, L5, T1and C3. All injections are subcutaneous and are made about 4 centimetersfrom the site of the tender point.

[0106] At 1 week a physical examination reveals no sign of fibromyalgiarelated pain.

Example 7

[0107] A patient, age 45, presents a pain in the upper chest whichcorresponds to the second rib region. The patient reports this specificpoint of pain to be the source of a general, diffuse pain that ispresent in the patient's upper body. The patient reports no othersymptoms. The patient is treated by an injection of a modifiedneurotoxin intramuscularly to the T2 dermatome approximately 20centimeters from the origin of the pain. Preferably, the modifiedneurotoxin is a modified botulinum type A, B, C₁, C₂, D, E, F or G. Theparticular dose as well as the frequency of administrations depends upona variety of factors within the skill of the treating physician. Within1-7 days after modified neurotoxin administration the patient's pain issubstantially alleviated. The duration of the pain alleviation is fromabout 1 to about 6 months.

Example 8

[0108] Upon examination, a 56 year old woman presents the presence ofmultiple tender points including those in the occipital, lower cervical,trapezium, gluteal, and greater trochanter areas bilaterally and in theleft knee. Pain is perceived to originate at the tender points andemanate from them forming a diffuse pain. The patient also reportssymptoms of irritable bowel and fatigue. She states that she has beensuffering from these symptoms for over a year and that just recently thepain she has been experiencing increases substantially. The patientundergoes surgery to repair torn cartilage in the left knee jointapproximately one year prior to the onset of the symptoms. The patientis treated by subcutaneous injection of a modified neurotoxin to siteswithin dermatomes that contain the tender points. The injections aremade about 6 centimeters from the site of the tender points. Themodified neurotoxin is, for example, a modified botulinum toxin type A,B, C1, C2, D, E, F and/or G. The modified neurotoxin may comprise, forexample, a leucine-based motif and/or additional tyrosine-based motifsand/or sites of phosphorylation. The particular dose as well as thefrequency of administration depends upon a variety of factors within theskill of the treating physician, as previously set forth. Within 1-7days after modified neurotoxin administration the patient's pain issubstantially alleviated. The duration of the pain alleviation is fromabout 7 to about 27 months.

Example 9

[0109] A 36 year old woman has a 15 year history of chronic pain in theupper torso area. Fifteen years prior to evaluation she notes a decreasein mobility in her left elbow and knees. The pain in the left side ofher body is thought to be worse than in the right. Upon examination itis revealed that the patient is pain sensitive to firm pressure that isapplied sequentially to thirteen of the eighteen fibromyalgia tenderpoints. She is diagnosed as having fibromyalgia and is treated withantidepressant medication including amytriptyline (Elavil). Themedication has little effect on the level of pain experienced by thepatient.

[0110] The patient is injected with botulinum toxin type A at locationson the body approximately nine centimeters from the center points offibromyalgia associated pain. Each injection is made within a dermatomethat des not encompass the source of the pain. The particular dose aswell as the frequency of administrations depends upon a variety offactors within the skill of the treating physician.

[0111] Several days after the injections she notes substantialimprovement in her pain. This gradually improves over a 2 to 3 weekperiod in which she notes increased mobility in her elbow and kneejoints. The patient states that the pain is better than at any time inthe last 4 years. The improved condition persists for up to 6 monthsafter injection of the neurotoxin.

Example 10

[0112] A 27 year old female patient presents with complaints of chronicpain and stiffness in various locations, including in her neck,shoulders, lower back, hips, and right leg. Additionally, the patientcomplains of headaches. She complains of neck pain and stiffness.

[0113] The patient is diagnosed with fibromyalgia with positive painsensitivity in 13 of the 18 fibromyalgia tender points (FIG. 1).

[0114] The patient is treated by intramuscular or subcutaneous injectionof 40 units of a botulinum toxin type A (or 2000 units of a botulinumtoxin type B) into her neck, which results is significant alleviation ofher fibromyalgia shoulder pain with 1-7 days. Subsequently, the patientis treated by intramuscular or subcutaneous injection of 40 units of abotulinum toxin type A (or 2000 units of a botulinum toxin type B) intoher shoulders, which results is significant alleviation of her both herlower fibromyalgia back pain and of her headaches.

[0115] At a further visit, the patient is treated by intramuscular orsubcutaneous injection of 40 units of a botulinum toxin type A (or 2000units of a botulinum toxin type B) into her lower back, which results issignificant alleviation of both her hip and leg fibromyalgia pains. Shealso reports further alleviation of her fibromyalgia shoulder pains.Fibromyalgia pain relief for each of the respective botulinum toxinadministrations, as set forth above, lasts for approximately fourmonths. This example shows that a botulinum toxin can be used toeffectively treat a fibromyalgia “referred pain; that is to treat afibromyalgia pain that is perceived by the patient at a location whichis both an anatomically distant location and at an anatomically distinctlocation, relative to the site at which the botulinum toxin isadministered to the patient.

[0116] Although the present invention has been described in detail withregard to certain preferred methods, other embodiments, versions, andmodifications within the scope of the present invention are possible.For example, a wide variety of neurotoxins can be effectively used inthe methods of the present invention. Additionally, the presentinvention includes administration of two or more neurotoxins, such astwo or more botulinum toxins, are administered concurrently orconsecutively. For example, botulinum toxin type A can be administereduntil a loss of clinical response or neutralizing antibodies develop,followed by administration of botulinum toxin type B. Alternately, acombination of any two or more of the botulinum serotypes A-G can beadministered to control the onset and duration of the desiredtherapeutic result. Furthermore, non-neurotoxin compounds can beadministered prior to, concurrently with or subsequent to administrationof the neurotoxin to proved adjunct effect such as enhanced or a morerapid onset of a pain suppression before the neurotoxin, such as abotulinum toxin, begins to exert its more long lasting pain suppressanteffect.

[0117] My invention also includes within its scope the use of aneurotoxin, such as a botulinum toxin, in the preparation of amedicament for the treatment of fibromyalgia.

[0118] All references, articles, patents, applications and publicationsset forth above are incorporated herein by reference in theirentireties.

[0119] Accordingly, the spirit and scope of the following claims shouldnot be limited to the descriptions of the preferred embodiments setforth above.

I claim:
 1. A method for treating fibromyalgia, the method comprisingthe step of administering a botulinum toxin to a patient afflicted withfibromyalgia.
 2. The method of claim 1 wherein the botulinum toxin isselected form the group consisting of botulinum toxin types A, B, C, D,E, F and G.
 3. The method of claim 1 wherein the botulinum toxin is abotulinum neurotoxin type A.
 4. The method of claim 1 wherein thebotulinum toxin is administered subcutaneously.
 5. The method of claim 1wherein the botulinum toxin is administered intramuscularly.
 6. A methodfor treating a fibromyalgia pain, the method comprising the step ofadministering locally a therapeutically effective amount of a botulinumneurotoxin to a patient with a fibromyalgia pain, thereby treating thefibromyalgia pain.
 7. The method of claim 6 wherein the botulinumneurotoxin is selected from the group consisting of botulinum neurotoxintypes A, B, C, D, E, F and G.
 8. The method of claim 6 wherein thebotulinum neurotoxin is a botulinum neurotoxin type A.
 9. The method ofclaim 6 wherein the botulinum neurotoxin is administered subcutaneouslyor intramuscularly.
 10. A method for treating fibromyalgia, the methodcomprising the step of administering a botulinum toxin to a patient withfibromyalgia, the botulinum toxin administering being carried out at afirst location which first location is anatomically distinct from and/oranatomically distant from a second location, at which second locationthe patient has a fibromyalgia pain which is alleviated by theadministration of the botulinum toxin at the first location, therebytreating fibromyalgia.
 11. The method of claim 10, wherein the firstlocation is a peripheral location.
 12. The method of claim 10, whereinthe second location is a locus of pain.
 13. The method of claim 10,wherein the administering step is carried out by subcutaneous orintramuscular administering of the botulinum toxin.
 14. The method ofclaim 10, wherein the first location is the head or neck of the patient.